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UVEA III Dr. K. Srikanth M.S;DO;D.N.B

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UVEA III

Dr. K. Srikanth M.S;DO;D.N.B

Glaucomatocyclitic crisis• a recurrent unilateral mild acute iritis• Symptoms are vague: discomfort, blurred vision, halos.

Signs include markedly elevated• lOP, corneal edema, fine KPs, low-grade cell and flare,

and a slightly dilated pupil. Episodes• last from several hours to several days. and recurrences

are common over many• years. Treatment is with topical corticosteroids and anti-

glaucoma medication• a diagnosis of exclusion

Lens-associated uveitis

• occur following disruption of the lens capsule (traumatic or surgical) or

• from leakage of lens protein through the lens capsule in mature or hypermature cataracts

• exact mechanism of lens-induced uveitis, although unknown, is thought to represent

• an immune reaction to lens protein

• Clinically, patients show an anterior uveitis that may be granulomatous or nongranulomatous.

• KPs are usually present and may be small or large. Anterior chamber reaction

• varies from mild to severe • hypopyon may be present.• Posterior synechiae are common, and lOP is often

elevated. • Inflammation in the anterior vitreous cavity is common,

but fundus lesions do not occur

• Histologically, a zonal granulomatous inflammation is centered at the site of lens

• . Neutrophils are present about the lens material with surrounding lymphocytes,

• plasma cells, epithelioid cells, and occasional giant cells.• Treatment consists of topical and, in severe cases, systemic

corticosteroids, as well as• cycloplegic and mydriatic agents. Surgical removal of all lens

material is usually curative.• When small amounts of lens material remain, corticosteroid

therapy alone may be sufficient• to allow resorption of the inciting material.

Fuchs heterochromic iridocyclitis• usually unilateral, and its symptoms vary• from none to mild blurring and discomfort• Signs include• diffuse iris stromal atrophy with variable pigment epithelial

layer atrophy • small white stellate KPs scattered diffusely over the entire

endothelium • diffusely distributed KPs also occur with herpetic keratouveitis• cells presenting in the anterior chamber as well as the

anterior vitreous

• Synechiae almost never form, but glaucoma and cataracts occur frequently

• The diagnosis is based on the distribution of KPs, lack of synechiae, lack of symptoms,

• and heterochromia• etiology of Fuchs heterochromic iridocyclitis remains unclear• prognosis is good• topical corticosteroids• generally do well with cataract surgery. and IOLs can usually be

implanted• Successfully• Glaucoma control can be difficult

Sympathetic Ophthalmia

• rare • bilateral • diffuse granulomatous non necrotizing panuveitis • that may develop after either surgical or accidental

trauma to 1 eye (the exciting eye)• followed by a latent period and the appearance of

uveitis in the uninjured fellow eye (the sympathizing eye).

• SO accounts for up to 2% of all uveitis cases

• accidental penetrating ocular trauma was the classic most common precipitating event for SO.

• Ocular surgery- particularly vitreoretinal surgery has now emerged as the main risk for the development of SO.

• reported to develop in 80% of patients within 3 months of injury and in 90% within I year.

• asymmetric bilateral panuveitis. • with more severe inflammation in the exciting eye than

in the sympathizing eye

• Signs and symptoms in the sympathizing eye vary in their severity and onset.

• minimal problems in near vision. • mild photophobia• slight redness to severe granulomatous anterior uveitis• mutton-fat KPs.• thickening of the iris from lymphocytic infiltration. • posterior synechiae formation and elevated lOP due

either to trabeculitis or to hypotony as a result of ciliary body shutdown

• Posterior segment findings indude moderate to severe vitritis with characteristic yellowish white. midequatorial choroidal lesions (so-called Dalen-Fuchs nodules) that may become confluent.

• Peripapillary choroidal lesions and exudative retinal detachment may• also develop • Structural complications of SO indude cataract, chronic CME, peripapillary and

macular CNV and optic atrophy

• A B

• A Peripapillary and multifocal choroiditis with exudative RD(macula)• B Peripheral multifocal choroiditiis with hazy view due to vitritis

• During the acute stage of the disease FA reveals multiple hyperfluorescent sites of leakage at the level of the RPE during the venous phase which persists in to the late stage of the study

• Pooling of dye is observed beneath areas of exudative neurosensory retinal detachment

• Dalen-Fuchs nodules appear hyperfluorescent early in the study

• Sympathetic ophthalmia A. . Fundus photograph showing a multifocal choroiditis.• B. Corresponding fluorescein angiogram disclosing multiple areas of alternating hyperfluorescence,• and blocked fluorescence at the level of the RPE

• Histologic features of SO are similar for both the exciting and sympathizing eye

• diffuse, granulomatous non necrotizing infiltration of the choroid with a predominance of lymphocyes, some epithelioid cells, few giant cells and plasma cells, and eosinophils in the inner choroid,

• nodular clusters of epithelioid cells containing pigment, located between the RPE and the Bruch membrane, corresponding to the Dalen Fuchs ( they may also be seen in patients with VKH syndrome and sarcoidosis )

• The diagnosis of SO is clinical and should be suspected in the presence of bilateral

• Uveitis following any ocular trauma or surgery• Differential diagnostic considerations include other

causes of pan uveitis. including tuberculosis. sarcoidosis. syphilis. and fungi. as well as traumatic or

• postoperative endophthalmitis• The course of SO is chronic. with frequent

exacerbations. and if left untreated SO• leads to loss of vision and phthisis bulbi

• Attempt should be made to salvage eyes with a reasonable prognosis for useful vision with meticulous and prompt closure of penetrating injuries;

• Enucleation within 2 weeks of injury to prevent the development of SO should be considered in patients with grossly disorganized globes with no discernible visual function.

• The initial treatment of SO involves systemic corticosteroids.• Corticosteroid-sparing agents such as azathioprine.

methotrexate. Mycophenolate mofetil. cyclosporine. chlorambucil and cyclophosphamide

• Topical corticosteroids together with cycloplegic and mydriatic agents are essential in the treatment of the acute anterior uveitis associated with SO.

• Periocular corticosteroids are used to manage inflammatory recurrences and CME.

• Intravitreal corticosteroids. including the intravitreal fluocinolone acetonide implant

Endophthalmitis• Intraocular inflammation predominantly involving

the inner spaces of the eye and its contents(vitreous &/or the AC)

• Post-operative endophthalmitis is the most common form.

• It comprises 70% of infective endophthalmitis

Classification

Endophthalmitis can be classified according to the

• Mode of entry• Type of etiological agent• Location in the eye

According to mode of entry

Exogenous Endogenous

•Micro-org directly introduced from environment

•Haematogenous spread of organisms as a metastatic infection

•Usually occurs following surgery:i.e. post-operative endophthalmitisor trauma i.e. post-traumatic or keratitis

•Structural defect of eye is not necessary

•Mainly bacterial •Common predisposing factors are immunocompromised status, septicemia or IV drug abuse

•Mainly fungal

Acc to aetiological agents

Bacterial Fungalviral Fungal

Parasitic

Endophthalmitis

Most common organisms responsible for endophthalmitis

Gram positive bacteria 75%-85% Gram negative bacteria 10%-15%

Staphylococcus epidermidis 43% Pseudomonas 8%

Streptococcus spp 20% Proteus 5%

Staphylococcus aureus 15% Haemophilus influenzae 0-1%

Propionibacterium acnes 30 reports Klebsiella 0-1%

Bacillus cereus 1% Coliform spp 0-1%

Fungi (rare)

Candida parapsilosis

Aspergillus

Cephalosporium spp.

Based on location in the eye

• When sclera participates Panophthalmitis• This classification of postoperative endophthalmitis includes the time of onset and• the organisms most frequently isolated:• acute-onset endophthalmitis (within 6 weeks of intraocular surgery):

coagulasenegative• Staphylococcus, S aureus, Streptococcus spp, gram-negative organisms• chronic (delayed-onset) endophthalm itis (beyond 6 weeks after surgery):

Propionibacterium• acnes, coagulase-negative Staphylococcus, fungi• bleb-associated endophthalmitis (months or years after surgery): Streptococcus

spp,• Haemophilus spp, gram-positive organisms

Symptoms:• Pain• Red eye• Decreased vision

Signs:• lid swelling• discharge • chemosis• Hazy cornea• Hypopyon• Vitritis .

Management• Detailed history• Ocular examination• Ultrasonography• Aqueous tap• Vitreous tap/biopsy

Treatment:

• Intravitreal antibiotics - mainstay of trt• Topical fortified antibiotics• Cycloplegics• Adjunctive systemic antibiotics,steroids

EVS recommends :

• a) Vitreous tap + A/C sampling + intravitreal Abx & steroids---- in cases VA >=HM.

• b) Vitrectomy + intravitreal antibiotics &steroids in cases VA < HM.

• Intravitreal antibiotics can be repeated every 48 hours according to the response

• Intravitreal antibiotics: Amikacin(0.4 mg in 0.1 ml) or Gentamycin (0.4 mg in 0.1 ml) Ceftrioxone(2 mg in 0.1 ml) + Vancomycin(1mg in 0.1 ml) +

Dexamethazone(0.4 mg in 0.1 ml)

• Intravitreal Antifungals: Amphotericin B (5 mcg in 0.1 ml)

Complications

• Panophthalmitis• Orbital cellulitis• Cavernous sinus thrombosis• Phthisis bulbi

• No PL,features s/o of Panophthalmitis Evisceration Frill excision